www.mghcme.org Neuropsychological Findings and Managing Educational Needs in ASD Ronna Fried, Ed.D Director of Neuropsychology Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD Bressler Program for Autism Spectrum Disorders Massachusetts General Hospital Assistant Professor of Psychology Harvard Medical School
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www.mghcme.org
Neuropsychological Findings and Managing Educational Needs in
ASD
Ronna Fried, Ed.D
Director of Neuropsychology
Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD
Bressler Program for Autism Spectrum Disorders
Massachusetts General Hospital
Assistant Professor of Psychology
Harvard Medical School
www.mghcme.org
Disclosures
I have the following relevant financial relationship with a commercial interest to disclose:
– receive grant support from the FDA ; Lundbeck
– In the past, I have received grant support from NIH and Shire.
www.mghcme.org
Benefits of a Neuropsychological Evaluations
• Confirm or clarify a diagnosis (ASD and/or ADHD)
• Provide profile of strengths and weaknesses for educational, vocational, or other services
• Document changes in functioning since prior examinations, including effects of treatment
• Clarify what compensatory strategies would help
• Result in referrals to other specialists
• Documents LD
www.mghcme.org
Motor,Skills
Communication Non-verbal Verbal
Measured I.Q.
Neuropsych
Deficits
Social-
Emotional
Interaction
Sensory
Awkward Agile
Severe Gifted
Significant Mild
Aloof Passive Active but Odd
Hypo Hyper
Autism Impairments
www.mghcme.org
Three Areas now Documented
• Theory of Mind (ToM)
• Central Coherence (CC)
• Executive Functions (EF)
AND COMORBIDITY CRITICAL TO TREATMENT
www.mghcme.org
Theory of Mind (ToM)
• Intuitively understand by age 4 that people have beliefs, wishes, desires, and opinions about the world which determine how they behave, rather than the actual physical world.
So:
*people can believe untrue things
*different people can believe different
things about the same affairs
www.mghcme.org
• Unseen Displacement (Sally-Anne, Maxi Task)
• Unexpected Contents (Smarties)
• Ice-Cream Man (Baron-Cohen, 1989) Prelock, P. (2011). Innovations in theory of mind assessment and intervention for children with ASD. www.theoryofmindinventory.com
• Difficulty taking into account what other people know or can be expected to know.
• Inability to read and react to the listener’s level of interest in what is being said.
• Inability to anticipate what others might think of one’s actions
• Inability to deceive or to understand deception: (Don’t tattle tale)
• Difficulty distinguishing between deliberate and accidental actions of another person (paranoia)
www.mghcme.org
Theory of Mind (ToM) in Testing
• Comprehension: own point of view e.g. why is news form newspaper better? “It is bad for brain to watch TV…reading good for you”
• Reading Comp questions about readers message : What he meant by…. “he did not mean that”
• What is alike : “there is nothing alike about those” (pedantic voice)
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Central Coherence
• Neurological impairments in those parts of the CNS that bring together perceptions, stimuli, experiences, memory, & relevance in order to synthesize appropriate contingent meaning for a particular point in time.
• fMRI indicates less connectivity between areas of brain needed for this function
www.mghcme.org
Effects of Impaired CC
• Reduced attention (focus) to the ‘big picture’ along with preference for details leads to:
– Egocentric behavior: Imposition of own perspective, preference for the known
– Difficulty choosing and prioritizing
– Difficulty seeing connections
• rule-bound behavior
www.mghcme.org
Testing and Central Coherence
• Reading Comp scores usually lower than Word Reading for inferential Questions
– Similarities- Cat and Mouse alike due to whiskers, tails, NOT stating animals
– Picture Concepts : gets stuck when 2 Alike in first two rows and cannot get third item
www.mghcme.org
• To use data from the MGH Bressler Clinic to assess neuropsychological profile of ASD
• To compare neuropsychological deficits of ASD with ADHD and healthy controls in both children to adults
• To focus on individuals with ASD who have IQ scores > 80
Current Study Objectives
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Neuropsychological Battery
• WASI
– Vocab
– Matrix
• WISC/WAIS
– Arithmetic
– Digit Span
– Letter Number
– Digit Symbol/Coding
– Symbol Search
• WRAT
– Arithmetic
• D-KEFS
– Color Word
– Trail Making
• TOWRE
– Sight Word
– Phonemic Decoding
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Children
ASD N=49
ADHD N=147
Controls N=32
FS IQ 104±12 103±11 106±13
Age 12.0 14.3 14.0
Sex(Male) 44 (90%) 110 (75%) 18 (56%)
SES 1.85 1.97 1.74
Adults ASD N=26
ADHD N=89
Controls N=138
FS IQ 109±12 108±14 112±11
Age 27.5 24.6 24.2
Sex(Male) 20 (77%) 45 (51%) 53 (38%)
SES 2.12 2.07 1.87
Demographics
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Full Scale IQ
ap<0.05 versus controls
bp<0.05 versus ADHD
a
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WASI Vocab
ap<0.05 versus controls
bp<0.05 versus ADHD
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WASI Matrix
ab
a
ap<0.05 versus controls
bp<0.05 versus ADHD
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• Executive functions (EFs) are mental operations involved in goal directed behavior and self regulation
– Set Shifting, Planning/Organizing, Working Memory, Inhibition, Attention, Self-Monitoring, Initiating, Emotional Control
• ASD is associated with neuropsychological deficits, including executive functioning deficits (EFDs)
Executive Functions
www.mghcme.org
Executive Functions
• Executive Functions (EF) are mental operations
involved in goal directed behavior and self-regulation
- Set Shifting
- Planning
- Working Memory
- Inhibition
- Attention
- Organization
- Emotional Dysregulation
www.mghcme.org
• ASD children compared to typical children – Problems with organizational skills (81%) – Handwriting (73%) – Explaining thoughts into words (77%) – Planning problems (78%) – Time management (80%) – One track mind
• The last to know and seek help if on the wrong track • Distressed if there is a schedule change • Does not have an‘inner’conversation to solve problems
Tony Attwood, 2007
Executive Functions
www.mghcme.org
Executive Function Deficits
• 2 or more tests < 25th percentile
– Processing Speed Index
– WISC/WAIS
• Digit Span, Letter Number, Arithmetic, Coding
– D-KEFS Color Word
• Inhibition, Switching
– D-KEFS Trail Making
• Contrast Measure, Number Letter
www.mghcme.org
Prior Study of EFDs (>2 tests)
• In children, ADHD with EFDs was associated with an increased risk for grade retention and a decrease in academic achievement, relative to ADHD alone.
• Adults with ADHD and EFDs had significantly lower levels of education, occupation, and overall socioeconomic status
• Adults with ADHD and EFDs had significantly more impaired interpersonal functioning
www.mghcme.org
Executive Function Deficits
ap<0.05 versus controls
bp<0.05 versus ADHD
a
ab a
www.mghcme.org
Working Memory Index
a
ap<0.05 versus controls
bp<0.05 versus ADHD
ab a
a
www.mghcme.org
• Tendency to lose track of what they’re doing while working on a problem (multi-step math)
• Forgetting one task while working on another part (reading comprehension)
• Inadequate space to hold ideas, facts or parts of procedures while working with them
Insufficient Working Memory
www.mghcme.org
• Is likely to be episodic
• Events are not stored in the context in which they occurred
• Lists of facts may be stored without a meaningful framework to link them
But Memory is Great
www.mghcme.org
Processing Speed Index
ap<0.05 versus controls
bp<0.05 versus ADHD
a
a a
www.mghcme.org
WISC/WAIS Coding
ap<0.05 versus controls
bp<0.05 versus ADHD
a
ab ab
www.mghcme.org
Set Shifting
• Ability to move from one situation, activity, or part of a problem to another as the condition demands
• Test
– Trails Making (D-KEFS)
– Intra-Extra Dimensional Shift Set (CANTAB),
• BRIEF examples
– Tries the same approach even when it does not work
– Has trouble moving from activity to activity
– Resists accepting a different solution
– Experiences anxiety, or extreme anger when things change
Roth, R.M., Isquith, P.K., & Gioia, G.A. (2005). Behavior rating inventory of executive function-adult version: Professional manual. Lutz, FL: PAR Psychological Assessment Resources, Inc.
www.mghcme.org
Trails Making
• Switch between connecting the numbers and letters
• Begin at number 1 and draw a line from 1 to A, A to 2, 2 to B, B to 3 and so on until you reach the end
G H I B C
10 2 4
7 8 9 J 1 3 D
6 A
F E
5
Start End
Delis, D.C., Kaplan, E., & Kramer, J.H. (2001). Delis-kaplan executive function system (d-kefs). San Antonio, TX: Pearson Education.
www.mghcme.org
D-KEFS Trail Making Number Sequencing
ap<0.05 versus controls
bp<0.05 versus ADHD
ab
www.mghcme.org
D-KEFS Trail Making Number Letter
ap<0.05 versus controls
bp<0.05 versus ADHD
a a
a
ab
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Color Word
red blue red
green red blue
red blue green
blue green red
Delis, D.C., Kaplan, E., & Kramer, J.H. (2001). Delis-kaplan executive function system (d-kefs). San Antonio, TX: Pearson Education.
www.mghcme.org
D-KEFS Color Word Inhibition SS
ap<0.05 versus controls
bp<0.05 versus ADHD
a a
a ab
www.mghcme.org
D-KEFS Color Word Switching SS
ap<0.05 versus controls
bp<0.05 versus ADHD
a
ab
www.mghcme.org
WRAT Arithmetic
ap<0.05 versus controls
bp<0.05 versus ADHD
a a
a
ab
www.mghcme.org
TOWRE Sight Word
ap<0.05 versus controls
bp<0.05 versus ADHD
a
ab
www.mghcme.org
TOWRE Phonemic Decoding
ap<0.05 versus controls
bp<0.05 versus ADHD
a a
a
a
www.mghcme.org
Shifting Deficits
• May learn a set of responses for a set situation
• May have a set of strategies, but not be aware they possess them or are unable to select a strategy for a new situation
Academic Example:
48 Tim has 48 stamps
23 48 23 71 and gets 23 more.
71 How many does he have now?
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ASD: Successful Classroom
• Clear, Consistent Routines (Daily Schedule)
• Flexibility in Programming-e.g. recess—specials, class choices